Laserfiche WebLink
Waste Tire Su, dey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 0 117 7 9.9 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t-� �-1 I ( _ ' Inspection Type(Fill one) <br /> Site Suffix: / / �9 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �Q� �\ If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 1.055 C <br /> o"' � <br /> ��J gsLos Inspection Date -1 / 05 / I j,Time In Time Out <br /> Business Rep Title ` 10 AM I l ®AM <br /> � 1 1 � O 5 � PM O 0 PM <br /> �[o� COLS Bone. Secv,' a C. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' ® Active 6 Passenger ® Generator ® Outdoor <br /> �+ Q Closed Q Altered <br /> GPa7 Latitude Q Hauler Q Indoor <br /> O Q Inactive S Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer QAuto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) ti <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments l , <br /> �1 L nM S _ C, tc__ <br /> C)W <br /> tcup_o-� (_O()(&n _ <br /> Inspection Form Included: Q <br /> Comments Included: ® 9;J � v. . <br /> '(OGD <br /> siness ep's Signature Phone Number �Specr's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:e Incorrect: EXAM P L E 1 2! 3 62081 <br /> ❑ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ■ <br />